National Center for Emerging and Zoonotic Infectious Diseases Vaccination Workshop for Immigrants Zachary White, MPH Public Health Advisor March 12, 2018
Learning Objectives After this workshop, you should be able to Explain the origins of vaccination requirement Use the Vaccine TI table and ACIP tables to determine which vaccines are needed and how to give them Complete the DS 3025 ACIP= Advisory Committee on Immunization Practices
Question I An adult applicant at your panel site is completing their medical exam. They ask if vaccinations are recommended or required in order for them to immigrate to the United States. Which is the best answer to their question? A. Vaccinations are recommended for their health B. The vaccinations are required C. I m not sure
Vaccinations in Immigration Law Immigration and Nationality Act (INA) amended in 1997 Immigrants not admissible if They fail to present documentation of having received vaccination against vaccine-preventable diseases including o Mumps, measles, rubella, polio, tetanus, diphtheria, pertussis, influenza B *, hepatitis B o Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) * Interpreted to mean Haemophilus influenzae type B
Question 2 The INA vaccine amendment applies to all of the following applicants EXCEPT: A. Diversity visa (DV) applicants B. Special immigrant visa (SIV) applicants C. Fiancé K visa applicants D. Adoptees
Those Included in the INA Amendment INA amendment applies to all immigrants including Immigrant visa (IV) applicants Diversity visa (DV) applicants Special immigrant visa (SIV) applicants Adoptees INA amendment does not apply to Refugees Asylees Parolees Nonimmigrants o K visa
Question 3 Two U.S. parents bring a 9-year-old orphan they are adopting into your office. You review the child s vaccine records. The parents state they want the child vaccinated in the United States. How do the parents accomplish this? A. Refuse to provide consent for examination B. Write to CDC for a waiver on medical grounds C. Apply for a waiver for all vaccinations on religious or moral grounds D. Sign an affidavit
Vaccination Exemption for Adoptees Amendment to INA Adoptees 10 years of age and younger Parents sign an affidavit Vaccinations will be provided after arrival to the United States Adoptees 11 years of age and older Follow Vaccine Technical Instructions
Clarifying ACIP Recommendations in the Context of Immigration ACIP recommends many vaccinations for many circumstances INA does not specify which ACIP recommendations to follow for applicants General public Travelers Special circumstances Immigrant vaccine requirements needed further clarification with new criteria
Criteria for Required Vaccinations for Immigration 2009 Federal Register Notice Criteria The vaccine must be age-appropriate for the immigrant applicant The vaccine must protect against a disease that has the potential to cause an outbreak in the US The vaccine must protect against a disease that has been eliminated or is in the process of being eliminated in the United States
Question 4 You live in a country that is endemic for yellow fever (YF). You examine an applicant who is 30 years old and last received a YF vaccine >10 years ago. Should you require the applicant to get a YF vaccine? A. No, YF is not a required vaccination for US immigration B. Yes, to protect the health of the individual applicant C. Yes, to protect the US population from reintroduction of YF D. No, the applicant doesn t need another YF vaccine dose as an adult
Required Vaccinations for US Immigration Mumps Measles Rubella Tetanus Diphtheria Meningococcal disease Pneumococcal disease Haemophilus influenzae type B Rot avirus Varicella Influenza Hepatitis A Hepatitis B Pertussis Polio
Vaccine Technical Instructions (TI) Developed by the CDC MAP team based on INA amendment and PRN criteria Goal Interpret the US immigration vaccine requirements into usable instructions for panel physicians about how they must vaccinate applicants Ensure applicants can present documentation of having received the age-appropriate required vaccinations for immigration
Why Update the Vaccination TIs? Make the TIs easier for panel physicians to understand Incorporate the answers to frequently asked questions Incorporate all relevant ACIP and vaccine updates that have occurred since 2009 Update links to helpful resources
Varicella verbal history clarification Changes to Vaccine Instructions DTaP/Tdap clarification and vaccine decision tool
Issues Vaccine TIs created to Address What is allowed as previous documentation? Who gives the vaccines? What vaccine recommendations are followed: In-country, World Health Organization (WHO), or ACIP? Which vaccines are required for applicants of different ages?
Process as Defined in the Technical Instructions Determine applicant s age Review his/her vaccination records and medical history Determine the vaccines applicant needs by referring to Vaccine TI table Current age-appropriate ACIP schedule Assess contraindications and precautions Determine if testing for laboratory evidence of immunity is indicated Provide needed vaccines Complete DS 3025
Vaccination Records
Question 5 Experience: Which of the following applies to your practice? A. We have never seen applicant vaccination records that we thought were fraudulent B. We rarely see vaccine records that we think are fraudulent C. We frequently see vaccine records that we think are fraudulent D. I am not a panel physician
Vaccination Records Acceptable for applicants to have received vaccinations prior to the panel physician encounter Applicants with appropriate documentation of receipt of vaccinations do not need to repeat those doses Examination of vaccination records is very important
Examination of Vaccine Records Are the dates of vaccination reasonable? Were the vaccines available on the dates of administration? If the record has handwriting: Is all the ink the same color? Does all the ink appear to have been written at the same time? Is handwriting different for different vaccines (at different times)? Is the format consistent with other records?
Question 6 You examine a 24-year-old applicant. He does not provide a vaccination record but is adamant he has been vaccinated. What should you do? A. Advise applicant to apply for a vaccine waiver B. Provide influenza and MMR vaccines C. Refuse to complete the medical examination before he provides vaccination records D. Write cdcqap@cdc.gov for advice E. Perform laboratory testing for immunity
Laboratory Evidence of Immunity Acceptable for the following diseases: Measles Mumps Rubella Hepatitis A Hepatitis B Polio Varicella Use kits that have regulatory approval in your country
Laboratory Confirmation of Immunity Laboratory confirmation not required for varicella if a reliable written or oral history of disease is provided New TIs further define what is considered an acceptable history: To verify a history of varicella, health care providers should inquire about: an epidemiologic link to another typical varicella case or to a laboratory confirmed case, or evidence of laboratory confirmation, if testing was performed at the time of acute disease Persons who have neither an epidemiologic link nor laboratory confirmation of varicella should not be considered as having a valid history of disease. CDC definition of typical varicella case The rash is generalized and pruritic (itchy). It progresses rapidly from macules to papules to vesicular lesions before crusting. The rash usually appears first on the head, chest, and back then spreads to the rest of the body. The lesions are usually most concentrated on the chest and back. In healthy children, varicella is generally mild, with an itchy rash, malaise, and temperature up to 102 F for 2 to 3 days. Infants, adults, and immunocompromised people are at risk for more severe disease and have a higher incidence of complications.
Question 7 Experience: Which of the following statements best describes your practice? A. We have immunity tests available, and we frequently use them for applicants B. We have immunity tests available, but we never use them C. We don t have immunity tests available D. I am not a panel physician
Question 8 You examine a 24-year-old female applicant who mentions that she can t wait to start a family in the US. She has no record of varicella vaccine, and states she had chicken pox at 7 years-old. What should you ask her next? A. In which arm would you like the varicella shot? B. Can you describe the symptoms you had at 7? C. Do you have any chicken pox scars? D. Were you seen by a doctor when you had chicken pox? E. B, C, and D
Countries of Origin of Cruise Ship Crew Members with Varicella Reported to CDC, January 2010-February 2016 Total number of cases = 422
Varicella Vaccination Keep in mind the following: For varicella, credible history of the disease is adequate at this time Ask questions to make sure applicant describes a clear history of the disease Exposure is likely to occur, so make sure the applicant understands the risk If history is uncertain, test for immunity can be used
Exercise: Review of Vaccination Records
Case 1
Case 2
Case 3
Break
How to Use Vaccine TI Table and Recommendations ACIP
The New Table
ACIP-recommended Immunization Schedule for Persons Ages 0 Through 18 Years United States, 2017 http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
ACIP-recommended Adult Immunization Schedule United States, 2017 https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf
Determining the Vaccines the Applicant Needs The applicant must show proof of having age-appropriate vaccination or immunity to the following diseases Diphtheria Tetanus Pertussis Polio Measles Mumps Rubella Rotavirus Haemophilus influenzae type b (Hib) Hepatitis A Hepatitis B Meningococcal disease Varicella Pneumococcal disease Influenza
Determining the Vaccines the Applicant Needs (cont d) If the applicant received one or more doses of a required vaccine and is due for the next dose in the series, it should be given at the medical examination If the applicant has not received any of the doses of a vaccine required for their age, the first dose should be given In order to determine the number of doses and spacing for each vaccine, use the standard ACIP recommendations; the TIs contain a link In addition to the standard ACIP recommendations, there are recommended doses for medical conditions and other situations such as pregnancy or travel; these additional vaccines are not required for immigration
Question 9 You examine a 13-year-old applicant who has documentation of receiving 1 polio vaccine, but no other vaccines. What table should you follow to determine the diseases she must be vaccinated against in order to immigrate to the US? A. ACIP routine immunization schedule for children B. WHO Expanded Programme on Immunization (EPI) schedule C. ACIP catch-up immunization schedule D. Vaccine TI table
Vaccine TI Table and ACIP Tables Vaccine TI table provides structure for meeting US immigration immunization requirements Where differences exist between vaccine TI table and ACIP tables: Follow vaccine TI table ACIP tables are comprehensive for that vaccine, including for contraindications Use as detailed resource once you commit to giving a specific vaccine based on the TI table
Strengths Vaccine TI Table Quick way to determine diseases an applicant must be vaccinated against All age groups are on one table Weaknesses Does not provide number of doses Does not explain spacing of doses Does not provide detailed information about contraindications
ACIP Tables Strengths Provides number of vaccine doses, spacing and catch up schedules Comprehensive information for specific vaccines including contraindications Weaknesses Multiple documents, lots of detail U.S. domestic recommendations for individual patient health, not immigration requirements Some differences from TIs (e.g., HPV, zoster)
Summary of Process for Using Vaccine TI and ACIP Tables Refer to Vaccine TI table Shows you which diseases an applicant must be vaccinated for by age Go to ACIP tables Age Number of doses needed, spacing, contraindications Where there are differences between vaccine TI table and ACIP tables Follow vaccine TI table
How to Complete the DS Forms
Question 10 A 22-year-old K visa applicant presents for her examination. She has been to the CDC website and knows she does not have to be vaccinated, so she did not bring her record. She asks why your nurse requested her vaccination record. What do you tell her? A. To understand her infectious disease risk B. Your nurse is confused C. To provide required vaccinations for U.S. immigration D. To provide a comprehensive vaccination record in English which she will need in the US
DS 3025 Officially: Documents whether or not applicant is inadmissible Documents that applicant has received required vaccinations In addition: Comprehensive vaccination record oresource for applicant after arrival to the United States Captures vaccine doses given as part of special program for U.S.-bound refugees
For All Applicants Obtain vaccine history Document vaccine history Provide a copy of the DS 3025 to the applicant
The Current DS-3025
DS-3025
The New Table
Sample of the CDC DTaP/Tdap decision tool
Identifying Potential Contraindications and Precautions to Vaccination A contraindication is a condition that is likely to result in a life-threatening problem if the vaccine is given A precaution is a condition that might increase the chance of a serious adverse reaction if the vaccine is administered or a condition that might compromise the immune response to the vaccine In general, panel physicians should not give a vaccine when a precaution or contraindication is present
Identifying Potential Contraindications and Precautions to Vaccination Resources ACIP immunization schedules footnotes The Pink Book s chapter on General Recommendations on Immunization gives a helpful summary of ACIP s contraindications, precautions, misconceptions about contraindications, and a list of screening questions that panel physicians can use Contraindications and precautions to specific vaccines are available at https://www.cdc.gov/vaccines/hcp/aciprecs/general-recs/contraindications.html For pregnant women, contraindications and precautions available at http://www.cdc.gov/vaccines/pubs/pregguide.htm
Vaccination Exemption for Adoptees Amendment to INA Adoptees 10 years of age or younger Parents may sign an affidavit Vaccinations will be provided after arrival to the United States Adoptees 11 years of age and older Follow Vaccination Technical Instructions
Blanket Waiver To our knowledge, no applicant has completed every required vaccine series at the time of the panel physician examination Therefore, Blanket Waiver is needed to allow immigration process to continue Blanket waivers for the specific reasons defined are given by the panel physician
DS 3025 Page 1 Vertical orientation All diseases listed must have a vaccine disposition Panel physician must sign and date the form
Immunization Record Record vaccines previously given to applicant in the first four columns Immigrants will only receive one dose of a specific required vaccine by the panel physician before travel Thus, only one column for vaccines you give
Blanket Waiver Category Examples A Age not appropriate If applicant does not need specific vaccine B Insufficient time interval to complete series Child receives dose in series but will travel before next dose is due C Contraindicated D Not routinely available In country or region Specific vaccine not licensed for age of applicant F Not flu season Influenza season is fall-winter in either hemisphere Tropics: Give if product available in your country o Not responsible for stocking both hemisphere vaccines H Known chronic hepatitis B virus infection Document if known, but do not test
Question 11 The panel physician has trouble ordering MMR vaccine from his usual supplier. Other physicians in the community have supplies. How is the DS 3025 documented? A. Coordinate with a new supplier or local pharmacy to obtain vaccine B. Mark Blanket waiver A not age appropriate C. Mark Blanket waiver B insufficient time interval D. Mark Blanket waiver D not routinely available
Question 12 You practice in a tropical country. An applicant visits you in September for a medical examination. What do you do about influenza vaccine? A. If available, provide either Southern Hemisphere vaccine or Northern Hemisphere vaccine B. Maintain stock of both Northern and Southern Hemisphere vaccine C. Provide Northern Hemisphere vaccine because applicant will immigrate to Northern Hemisphere D. Perform laboratory testing for immunity
Summary for Immigrant Visa Applicants Complete, but requests a Blanket Waiver Applicant is admissible U.S. vaccination requirements not complete Individual waiver o Must be opposed to all vaccinations o Applicant should discuss the waiver process with the Consular Section Adoptee exemption Applicant refuses vaccinations Not Admissable!
Refugee Vaccine Initiative CDC partnering with the International Organization for Migration (IOM) and U.S. Department of State to vaccinate refugees Doses provided through that program are documented in these columns Initiative uses different guidance provided by CDC than what is in the Vaccine TI
DS 3025 Page 2
Vaccine Resources for Panel Physicians Handling, Storage, and Administration: Pink Book chapter on Vaccine Storage and Handling, CDC s Vaccine Storage and Handling website, and http://www.immunize.org/packageinserts/ Counseling and Resources: Vaccine Information Statements Advisory Committee on Immunization Practices (ACIP) Schedules and Updates: links included to both Epidemiology and Prevention of Vaccine-Preventable Diseases Pink Book
Helpful Resources Pink Book page explaining all contraindications and helpful screening questions in a box http://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html Table of contraindications http://www.cdc.gov/vaccines/hcp/admin/contraindications-vacc.html Guidelines for Vaccinating Pregnant Women http://www.cdc.gov/vaccines/pregnancy/hcp/guidelines.html Vaccine Storage and Handling Toolkit http://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html Pink Book= Epidemiology and Prevention of Vaccine-Preventable Diseases
Coming soon!
Thank you cdcqap@cdc.gov http://www.cdc.gov/panelphysicians http://www.cdc.gov/vaccines/schedules/hcp For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 Visit: www.cdc.gov Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Global Migration and Quarantine
Cases
Answers 1. B 2. C 3. D 4. A 5. A 6. E 7. A 8. E 9. D 10. D 11. A 12. A